Drug Quantity Limits List To help make the use of prescription drugs safer and more affordable, Alabama PEEHIP is using a comprehensive Drug Quantity Management program effective October 1, 2009. For the medications listed below, Alabama PEEHIP will cover the amount needed to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). Based on the FDA’s guidelines and other medical information, Alabama PEEHIP developed this program together with Express Scripts, the company chosen to manage our prescription drug benefit. This list is updated regularly by the Express Scripts Therapeutic Assessment Committee. Both the brand and generic version of a medication (when available) are subject to the limits listed below. Alabama PEEHIP covers up to a 30-day supply of most medications, and up to a 90-day supply of medications on the maintenance list, at the quantities listed below. Your doctor may request a clinical prior authorization where appropriate by calling the PEEHIP-exclusive Prior Authorization Department at 1-800-347-5841. If the prior authorization is approved, you may receive more than the recommended quantity listed below. This list is subject to change and does not guarantee coverage. Name of Prescription Drug Abilify 2, 5, 10, 15, 20 and 30 mg Abilify DISCMELT 10mg and 15mg Actiq 200mcg, 400mcg, 600mcg, 800mcg, 1200mcg, and 1600mcg Actonel 35 mg Actonel 5 and 30 mg Actonel 75 mg Actonel 150 mg Actonel with Calcium tablets Actoplus Met 15/500mg and 15/850mg Actos 15, 30, 45 mg Adcirca 20 mg tablets Advair Diskus 100/50, 250/50, and 500/50 with device Advair HFA Advicor 500/20 Advicor 750/20, 1000/20 Aerobid/Aerobid-M 7 grams Aerospan 80mcg 8.9 gram Aerospan 80mcg 5.1 gram Albuterol generic inhaler Allegra 180 mg Alendronate 35 and 70 mg Alendronate 5, 10, and 40 mg Allegra 30, 60mg Allegra-D 12 hour Allegra-D 24 hour Alora Aloxi 0.5mg Aloxi injection 0.25 mg/5 ml and 0.075 mg/1.5 ml Altoprev 10, 20, 40, 60 mg Alupent 14 grams Alvesco 80 mcg

Maximum Quantity 1 tablet daily 2 tablets per day 90 units per 30 days 1 tablet per week 1 tablet daily 2 tablets per month 1 tablet per month 1 tablet daily 3 tablets per day 1 tablet daily 2 tablets daily 14, 28, 120 blisters based on package size 2 inhalers per month 1 tablet daily 2 tablets per day 3 inhalers per month 3 inhalers per month 1 inhaler per rx 3 inhalers per month 1 tablet daily 1 tablet per week 1 tablet daily 2 tablets/orally disintegrating tablets per day 2 tablets per day 1 tablet daily 2 patches per week 1 capsule per rx 1 vial per rx 1 tablet daily 3 inhalers per month 2 inhalers per month

Page 1 of 9 Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09

Name of Prescription Drug Alvesco 160 mcg Ambien 5, 10 mg Ambien CR 6.25mg and 12.5mg Amerge 1, 2.5 mg Anzemet 50, 100 mg Aplenzin 174, 348, 522 mg Arava 10 mg, 20 mg Asmanex 14 inhalation units Asmanex 30, 60, 120 inhalation units Astelin Nasal Spray (34 ml bottle) Astepro137 mcg nasal spray Atrovent HFA 12.9 grams Atrovent inhaler 14.7 grams Atrovent nasal spray 0.03% (30 grams), generic Atrovent nasal spray 0.06% (15 grams), generic Avandamet 1 mg/500 mg, 2/500, 4/500, 2/1000, 4/1000 Avandaryl 4mg/1mg, 4mg/2mg, 4mg/4mg, 8mg/2mg, 8mg/4mg Avandia 2, 4 mg Avandia 8 mg Avonex Axert 6.25 mg Axert 12.5 mg Azithromycin Azithromycin 500mg Azmacort 20 grams Beconase AQ 25 grams Betaseron Boniva 2.5 mg Boniva 150 mg Brovana Inhalation Solution (30 vial carton) Bupropion SR/ER 100, 150 mg Budeprion SR 100, 150 mg Bupropion SR/ER 200 mg Budeprion XL 300 mg Butorphanol tartrate Nasal Spray Byetta 1.2 ml (250 mcg/ml) Byetta 2.4 ml (250 mcg/ml) Cabergoline 0.5mg Caduet 5/10,10/10, 5/20, 10/20, 5/40, 10/40, 5/80, 10/80, 2.5/10, 2.5/20, 2.5/40, 5/20, 5/40 mg Catapres-TTS Patches Cardura 1 mg Cardura 2, 4 mg Cardura 8 mg Cardura XL 4, 8 mg Caverject Celexa 10 mg Celexa 20 mg

Maximum Quantity 3 inhalers per month 15 tablets per 30 days 15 tablets per 30 days 9 tablets per rx; 18 tablets per 28 days 1 tablet per rx 1 tablet daily 1 tablet daily 1 inhaler per rx 2 inhalers per month 2 bottles per month 2 bottles per month 2 inhalers per month 3 inhalers per month 2 bottles per month 2 bottles per month 2 tablets per day 1 tablet daily 2 tablets per day 1 tablet daily 4 syringes per month 6 tablets per rx; 18 tablets per 28 days 12 tablets per rx; 24 tablets per 28 days See Zithromax 4 tablets per rx 3 inhalers per month 2 inhalers per month 14 or 15 vials with prefilled diluent syringe per month (depending on product packaging) 1 tablet daily 1 tablet per month 2 cartons per month 2 tablets per day 2 tablets per day 2 tablets per day 1 tablet daily 2 spray bottles per month 2 syringes per month 2 syringes per month 10 tablets per month 1 tablet daily 1 patch weekly 1 tablet daily 1 tablet daily 2 tablets per day 1 tablet daily 12 vials, kits, or ampules per rx 1 tablet daily 1 tablet daily

Page 2 of 9 Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09

Name of Prescription Drug Celexa 40 mg Cesamet Chorionic gonadotropin 10000 units, generic Citalopram 10mg, 20mg, and 40mg Clarinex/Clarinex Reditabs 5 mg Clarinex 2.5mg Reditabs Clarinex-D 12 hour Clarinex-D 24 hour Claritin 10 mg/Claritin Reditabs 10 mg, Claritin 5 mg chewable tablets Claritin-D 12 Hour Claritin-D 24 Hour Climara, Climara Pro Combivent 14.7 grams Copaxone 20 mg kit Cordran Tape Crestor 5, 10, and 20 mg Crestor 40 mg Cymbalta 20mg Cymbalta 30mg and 60mg Dalmane 15mg, 30mg Depo-Provera Contraceptive Injection 150 mg/mL Depo-Sub Q Provera 104 Diflucan 150 mg Ditropan XL 5 mg Divigel 0.25, 0.5, and 1 grams Doral 7.5mg, 15mg Dostinex 0.5 mg Doxazosin 1, 2, 4 mg Doxazosin 8 mg Duetact 30/2mg and 30/4mg Duoneb 3 ml vial Edex Edluar 5 and 10 mg Effexor XR 37.5 mg capsules Effexor XR 75 mg capsules Effexor XR 150 mg capsules Effexor 25 mg, 37.5 mg, 50 mg and 75 mg tablets Effexor 100 mg tablets Elestrin gel pump Emend 115mg vial Emend 125 mg Emend 40mg capsule Emend 80 mg Emend Bifold Pack Emend Trifold Pack (one 125 mg and two 80 mg capsules)

Maximum Quantity 1 tablet daily 30 capsules per rx 3 vials per rx 1 tablet daily 1 tablet daily 1 tablet daily 2 tablets per day 1 tablet daily 1 tablet daily 2 tablet per day 1 tablet daily 1 patch per week 3 inhalers per month 1 kit (30 prefilled syringes) per month 2 rolls of tape per month 1 tablet daily 1 tablet daily 2 tablets per day 1 tablet daily 15 capsules per 30 days 1 vial/syringe per rx 1 syringe per rx 2 tablets per rx 1 tablet daily 1 packet daily 15 tablets per 30 days 2 tablets per week 1 tablet daily 2 tablets per day 1 tablet daily 205 vials (package size 3) per month 12 vials or kits per rx 15 tablets per 30 days 1 tablet daily 3 capsules per day 1 capsule daily 3 tablets per day 3 tablets per day 1 pump per month 1 vial per rx 1 capsule per rx 1 capsule per rx 2 capsules per rx 1 pack per rx 1 pack (package size 3) per rx

Page 3 of 9 Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09

Name of Prescription Drug Enbrel 25mg vials Enbrel 25 mg syringes Enbrel 50mg syringe/auto injectors

Maximum Quantity 8 vials per 28 days;10 vials per rx w/PA 8 syringes per 28 days; 10 syringes per rx w/PA 4 syringes/auto injectors per 28 days; 5 syringes/auto injectors per rx w/PA 3 units or 2 twin packs per rx 2 patches per week 15 tablets per 30 days 2 patches per week 1 patch per week 2 packets per day 2 pump bottles per month 2 pumps per month 7 tablets per rx 21 tablets per rx 68 tablets per rx 21 tablets per rx 90 units per 30 days 90 units per 30 days See Allegra 60 patches per month 2 bottles per month 2 inhalers per month 5 inhalers per month 2 inhalers per month 1 inhaler per rx 3 inhalers per month 2 tablets per rx 3 inhalers/bottles per rx 1 capsule/tablet daily 2 capsules per day 15 capsules per 30 days 2 bottles per month 3 tablets per day 1 tablet daily 2 tablets daily 1 package (package size 12) 12 caps per rx 2 packages (package size 60) 120 caps per month 1 pen per month 1 tablet per week 1 tablet daily 5 bottles per month 1 tablet per week 9 tablets per rx, 27 tablets per 28 days 1 packet daily 2 capsules per day

EpiPen, EpiPen Jr. Esclim Estazolam 1 mg, 2 mg Estraderm Estradiol transdermal patch Estrasorb Estrogel .06% 50gm Evamist 1.53 mg spray Factive 320mg Famvir 125 mg Famvir 250 mg Famvir 500 mg Fentanyl citrate, oral transmucosal, all strengths Fentora all strengths Fexofenadine Flector 1.3% patch Flonase 16 grams Flovent 50mcg and 100mcg Diskus Flovent 250mcg Diskus Flovent HFA 44mcg Flovent HFA 110mcg Flovent HFA 220mcg Fluconazole 150mg Flunisolide 0.025% Fluoxetine 10 mg Fluoxetine 40 mg Flurazepam 15 mg, 30 mg Fluticasone Nasal Spray Fluvoxamine 100 mg Fluvoxamine 25 mg Fluvoxamine 50 mg Foradil Aerolizer & 12 capsules in blisters Foradil Aerolizer & 60 capsules in blisters Forteo 600mcg/2.4ml pen Fosamax 35 and 70 mg Fosamax 5, 10, and 40 mg Fosamax 70 mg/75 mL oral solution Fosamax Plus D 70 mg/2800 IU, 70mg/5600 IU Frova 2.5 mg Gelnique 10% gel Geodon 20, 40, 60 and 80 mg

Page 4 of 9 Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09

Name of Prescription Drug Halcion 0.125 mg, 0.25 mg Humira 20 mg and 40 mg syringe/pen

Maximum Quantity 15 tablets per 30 days 2 syringes/pens per 30 days; 3 syringes/pens per rx w/PA 2 syringes per 30 days; 3 syringes per rx w/PA 2 syringes per 30 days; 3 syringes per rx w/PA 1 capsule daily 2 capsules per day 1 capsule daily 14 bottles per month 1 kit (2 syringes) per rx; 8 kits per 30 days 1 kit (2 syringes) per rx; 8 kits per 30 days 2 vials per rx; 16 vials per 30 days 6 nasal spray devices per rx; 18 nasal spray devices per 30 days 6 nasal spray devices; 36 nasal spray devices per 30 days 9 tablets per rx; 18 tablets per 28 days 2 inhalers per month 2 inhalers per month 1 tablet daily 2 tablets per day 1 capsule daily 2 tablets per day 1 tablet daily 1 capsule daily 20 tablets per rx 2 tablets per rx 1 bottle per rx 1 capsule daily 2 capsules daily 1 tablet daily 1 tablet daily

Humira Crohn’s Starter Pack Humira Psoriasis Starter Pack Hytrin 1 mg Hytrin 10 mg Hytrin 2 and 5 mg IB Stat oral spray 30 mL Imitrex Injection (syringes/cartridges) Imitrex 4mg injection (syringes/cartridges) Imitrex Injection (vials) Imitrex Nasal Spray 5 mg Imitrex Nasal Spray 20 mg Imitrex tablets 25, 50, and 100 mg Intal Inhaler 112 Intal Inhaler 200 Invega 3, 9 mg Invega 6 mg Itraconazole 100mg Janumet 50/500 mg, 50/1000 mg Januvia 25mg, 50mg, 100mg Kapidex 30mg Ketoralac 10 mg Kytril 1 mg Kytril solution 2 mg/10 mL Lescol 20 mg Lescol 40 mg Lescol XL 80 mg Lexapro 5, 10, and 20 mg Lioresal Inthrathecal Refill Kit 1 ampule 10 mg/20 ml 2 ampules 10 mg/5 ml 1 ampule 40 mg/20 ml Lipitor 10, 20, 40 , and 80 mg Lovastatin 10 mg Lovastatin 20 and 40 mg Lunesta 1mg, 2mg, 3mg Luvox CR 100mg and 150mg Maxair Autohaler 14 grams Maxalt and Maxalt-MLT 5, 10 mg Menostar Mevacor 10 mg Mevacor 20 mg Mevacor 40 mg Miconazole Migranal 4 mg/ml Mobic 7.5 mg

1 kit per month 1 tablet daily 1 tablet daily 2 tablets per day 15 tablets per 30 days 2 tablets per day 2 inhalers per month 12 tablets per rx; 24 tablets per 28 days 1 patch per week 1 tablet daily 2 tablets per day 2 tablets per day See Monistat 8 spray devices per rx and per 28 days 1 tablet daily Page 5 of 9

Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09

Name of Prescription Drug Monistat 1 pre-filled Monistat 3 combination pack 200 mg & equivalent Monistat 3 suppositories 200 mg & equivalent Monistat 7 combination pack & equivalent Monistat 7 cream and equivalent Monistat 7 cream pre-filled applicators Monistat 7 suppositories 100 mg & equivalent Monistat Dual Pak (1200 mg vaginal insert, 9 gram 2% cream) Monistat Dual-Pak (three 200 mg vaginal supp, 15 gram 2% cream) Muse Nasacort 10 gram Nasacort AQ 16.5 gram Nasarel 0.025% 25 mL Nasonex 50 mcg nasal spray 17 gram NebuPent 300 mg/container Neumega Newtek disposable blood glucose meter Nexium 20 mg Nexium 10 and 20 mg packets Noverel 10,000 unit Omeprazole 10 mg Omnaris 50 mcg nasal spray Ondansetron 24 mg Ondansetron, Ondansetron ODT 4 and 8 mg Ondansetron solution 4 mg/5 mL Onglyza 2.5 and 5 mg tablets Oxybutynin XL 5 mg Oxycodone ER, SR 10mg, 20mg, 40mg, 80mg OxyContin 10mg, 20mg, 40mg, 80mg Oxytrol Patch Pantoprazole 20 mg paroxetine HCl 10, 20, 30, and 40 mg, paroxetine CR 12.5, 25, 37.5 mg Patanase 0.6% Nasal Spray Paxil 10 mg Paxil 20 mg Paxil 30 mg Paxil 40 mg Paxil CR 12.5, 25, 37.5 mg PEG Intron Pens/Kit (containing 1 vial each) 50 mcg, 80 mcg, 120 mcg, 150 mcg Pegasys 180 mcg Pegasys 180 mcg Convenience Pack ( 4 vials) Pegasys 180 mcg Convenience Pack (4 prefilled syringes) Perforomist Inhalation Solution Pexeva 10 mg Pexeva 20 mg Pexeva 30 mg Pexeva 40 mg

Maximum Quantity 1 box per rx 1 box per rx 3 (1 box) per rx 1 box (7 suppositories, 9 gram cream) per rx 45 grams (1 tube) per rx 7 applicators per rx 7 suppositories (1 box) per rx 1 (1 box) per rx 1 (1 box) per rx 12 urethral suppositories per rx 3 inhalers per month 2 bottles per month 3 bottles per month 2 bottles per month 1 container (inhaler) per month 21 vials per rx 2 meters per rx 1 capsule daily 1 packet daily 3 vials per rx 1 capsule daily 2 bottles per month 1 tablet per rx 12 tablets per rx 3 - 50 mL bottles per rx 1 tablet daily 1 tablet daily 120 tablets per 30 days 120 tablets per 30 days 2 patches per week 1 tablet daily See Paxil 2 tablets per day 2 bottles per month 1 tablet daily 2 tablets per day 2 tablets per day 1 tablet daily 2 tablets per day 5 pens/vials per month 5 vials (package size 1) per month 1 box (package size 1) per month 1 box (package size 1) per month 2 cartons (120 vials) per month 1 tablet daily 2 tablets per day 2 tablets per day 1 tablet daily

Page 6 of 9 Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09

Name of Prescription Drug Plan B PrandiMet 1mg/500mg, 2mg/500mg Pravachol 10, 20, 40, 80 mg Pravastatin 10, 20, 80 mg Pravastatin 40mg Pravigard PAC 81-20, 325-20, 81-40, 325-40, 81-80, and 325-80 Pregnyl 10,000 unit Prevacid 15 mg, Prevacid SoluTab Prevpak patient pack Prilosec 10 mg Prilosec 20 mg (Brand) Prilosec 10 mg oral suspension packets Prilosec 2.5 mg oral suspension packets Pristiq 50 mg and 100 mg tablets Proair HFA Prosom 1mg, 2mg Protonix 20 mg Proventil Inhaler 17 gram Proventil HFA 6.7 gram Prozac 10 mg Prozac 40 mg Prozac Weekly 90 mg Pulmicort Flexhaler 90 mcg Pulmicort Flexhaler 180 mcg Pulmicort Respules 0.25 mg/2 mL and 0.5 mg/2 mL Pulmicort Respules 1 mg/2 mL Pulmicort Turbuhaler Qvar 40, 80mcg (7.3 grams) Rebetron Combination, Rebetron 1200, 1000, and 600 Therapy Pak Rebif 22 mcg and 44 mcg Rebif Titration Pack 4.2ml Regranex 0.01%gel 2, 7.5, and 15 gm Relenza 5 mg/blister with inhalation device Relpax 20 mg and 40 mg Restasis 0.05% Restoril 15mg, 30mg Revatio 20mg Rhinocort Aqua 32 mcg (120 inhalations) 8.4ml bottle Risperdal 0.25, 0.5, 1, 2, 3, and 4 mg Risperdal M-Tab 0.5, 1, 2, 3 and 4 mg risperidone 0.25, 0.5, 1, 2, 3, and 4 mg risperidone M-Tab 0.5, 1, 2, 3 and 4 mg Rozerem 8mg Samsca 15 mg Samsca 30 mg Sancuso Patch 34.3 mg Sandostatin LAR Depot 10 mg/5 ml and 30 mg/5 ml Sandostatin LAR Depot 20 mg/5 ml

Maximum Quantity 2 tablets per rx 5 tablets per day 1 tablet daily 1 tablet daily 1 tablet daily 1 package per month Package size is 30 3 vials per rx 1 capsule/tablet daily 14 units (1 package) per rx 1 capsule daily 1 capsule daily 1 packet daily 2 packets per day 1 tablet daily 3 inhalers per month 15 tablets per 30 days 1 tablet daily 3 inhalers per month 3 inhalers per month 1 capsule/tablet daily 2 capsules per day 1 capsule per week 2 inhalers per month 3 inhalers per month 70 ampules per month 35 ampules per month 2 inhalers per month 3 inhalers per month 2 packages per month 15 syringes per month 1 package per month 1 tube per rx 20 blisters per rx; 40 blisters per 365 days 6 tablets per rx; 18 tablets per 28 days 2 vials per day 15 capsules per 30 days 3 tablets per day 3 bottles per month 2 tablets per day 2 tablets per day 2 tablets per day 2 tablets per day 15 tablets per 30 days 1 tablet daily 2 tablets per day 1 patch per rx 1 vial per rx 2 vials per rx

Page 7 of 9 Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09

Name of Prescription Drug Sarafem 10 mg Sarafem 15mg Sarafem 20 mg Savella 12.5 mg, 25 mg, 50 mg Savella 100 mg Savella Titration Pack Selfemra 10mg Selfemra 20mg Serevent Diskus 28 blisters Serevent Diskus 60 blisters Seroquel 25, 50mg, 100 mg Seroquel 200 mg Seroquel 300 mg, 400mg Seroquel XR 150mg, 200mg Seroquel XR 50mg, 300mg, 400mg Sertraline 100 mg and 50mg Sertraline 25 mg Simcor 500/20mg Simcor 750/20mg, 1000/20mg Simvastatin 20 mg Simvastatin 5, 10, 40, 80 mg Sonata 10 mg Sonata 5 mg Spiriva Handihaler 6 capsules (1 blister card) with inhaler device Spiriva Handihaler 30 capsules (5 blister cards) with inhaler device Spiriva Handihaler 90 capsules (6 blister cards) with inhaler device Sporanox 100 mg Stadol Nasal Spray 2.5 mL Suboxone 2/.0.5 mg Suboxone 8/2 mg Symbicort 80/4.5, 160/4.5 Inhaler Symlin 0.6mg/ml SymlinPen 60, 120 pen injector Tamiflu 30 mg Tamiflu 45 mg, 75 mg Tamiflu for oral suspension, 25 mL Temazepam 15mg, 30mg Terazol 3 Terazol 3 Cream 0.8% Terazol 7 Cream 0.4% Terazosin generic 1 mg Terazosin generic 2 and 5 mg Terazosin generic 10 mg Terconazole Tilade 16.2 grams TOBI 300 mg Toradol 10 mg Treximet 85 mg/500 mg Triazolam 0.125 mg, 0.25 mg

Maximum Quantity 1 capsule/tablet daily 1 tablet daily 4 capsules or tablets per day 2 tablets per day 2 tablets per day 55 tablets per month 1 capsule daily 4 capsules daily 1 package per rx 2 packages per month 3 tablets per day 3 tablets per day 2 tablets per day 1 tablet daily 2 tablets per day 2 tablets per day 1 tablet daily 1 tablet daily 2 tablets per day 1 tablet daily 1 tablet daily 15 capsules per 30 days 15 capsules per 30 days 1 package per rx 2 packages per month 1 package per month 1 capsule daily 2 spray bottles 3 tablets per day 3 tablets per day 2 inhalers per month 7 vials per month 8 pens per month 20 capsules per rx; 40 capsules per 365 days 10 capsules per rx; 20 capsules per 365 days 3 bottles per rx; 6 bottles per 365 days 15 capsules per 30 days 3 (1 box) per rx 1 tube (of the 20 gram) per rx 1 tube (of the 45 gram) per rx 1 capsule daily 1 capsule daily 2 capsules per day See Terazol or Zazole 3 inhalers per month 56 ampules per month 20 tablets per rx 9 tablets per rx; 18 tablets per 28 days 15 tablets per 30 days

Page 8 of 9 Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09

Name of Prescription Drug Twinject 0.3mg or 0.15mg Auto-Injector Valtrex 1 gram Valtrex 500 mg Venlafaxine extended-release tablets 37.5, 75 and 150 mg Venlafaxine extended-release tablets 225 mg Ventolin HFA 90 mcg (18 grams) Ventolin HFA 90 mcg (8 grams) Veramyst Nasal Spray Vivelle Vivelle-Dot Vytorin 10/10,10/20,10/40, 10/80mg Wellbutrin SR 100, 150 mg Wellbutrin SR 200 mg Wellbutrin XL 150 mg Wellbutrin XL 300 mg Xolair 150 mg/5 ml single-use vial Xopenex HFA Xyzal Zazole Cream 0.4% Zazole Cream 0.8% Zazole 80mg Vaginal Supp Zegerid 20 mg Zithromax for oral suspension 100 mg/5 mL, 15 ml bottle Zithromax for oral suspension 200 mg/5 mL, 15 and 22.5 ml bottle Zithromax for oral suspension 200 mg/5 mL, 30 ml bottle Zithromax tablet or capsule, 250 mg Zithromax tablet, 500 mg Zmax 60 ml Zocor 20 mg Zocor 5, 10, 40, 80 mg Zofran 24 mg Zofran, Zofran ODT 4 and 8 mg Zofran solution 4 mg/5 mL Zoloft 100 mg Zoloft 25 mg Zoloft 50 mg Zolpidem tartrate 5 and 10 mg Zomig/Zomig-ZMT 2.5 and 5 mg Zomig Nasal Spray 5 mg Zyprexa 2.5, 5, 7.5, 10, 15, and 20 mg Zyprexa Zydis 5, 10, 15, and 20 mg Zyrtec, Zyrtec chewable 5 and 10 mg Zyrtec-D 12 Hour

Maximum Quantity 3 units or 2 twin packs per rx 1 caplet (tablet) daily 1 caplet (tablet) daily 1 tablet daily 1 tablet daily 3 inhalers per month 1 inhaler per rx 2 bottles per month 2 patches per week 2 patches per week 1 tablet daily 2 tablets per day 2 tablets per day 1 tablet daily 1 tablet daily 6 vials per month 3 canisters per month 1 tablet daily 1 pack (45 gram) per rx 1 pack (20 gram) per rx 3 (1 box) per rx 1 tablet daily 2 bottles per rx 3 bottles per rx 3 bottles per rx 8 tablets/capsules per rx 4 tablets per rx 1 bottle per rx 1 tablet daily 1 tablet daily 1 tablet per rx 12 tablets per rx 3 - 50 mL bottles per rx 2 tablets per day 1 tablet daily 2 tablets per day 15 tablets per 30 days 6 tablets per rx; 18 tablets per 28 days 6 nasal spray devices per rx; 18 nasal spray devices per 28 days 1 tablet daily 1 tablet daily 1 tablet daily 2 tablets per day

Page 9 of 9 Drug Quantity Limits List: Subject to change; Does not guarantee coverage; Limits adjust based on days supply dispensed

08/21/09